Skip to main content
SpringerLink
Log in

Management of Lower Gastrointestinal Bleeding in Older Adults

  • Therapy in Practice
  • Published:
Drugs & Aging Aims and scope Submit manuscript

Abstract

Lower gastrointestinal bleeding, acute overt, occult or obscure in nature, causes significant morbidity and mortality in older adults. As the elderly population is expected to increase in the future, healthcare costs and the clinical burden of lower gastrointestinal bleeding will rise. Lower gastrointestinal bleeding, by definition, originates from a site distal to the ligament of Treitz and is usually suspected when patients present with haematochezia, or maroon stools per rectum. A thorough history is paramount in guiding the diagnostic steps and management but is frequently inadequate in elderly, poorly communicating, nursing home patients. The causes of lower gastrointestinal bleeding in older adults may be anatomic, vascular, inflammatory, neoplastic or iatrogenic. Comorbidity from cardiopulmonary disease, renal disease, diabetes or underlying cancer, all prevalent in older adults, may affect the incidence, severity, morbidity and mortality of lower gastrointestinal bleeding in the elderly. The use of multiple medications, particularly non-steroidal anti-inflammatory, antiplatelet and anticoagulant agents, needs to be always considered in elderly patients with lower gastrointestinal bleeding and anaemia. CT imaging and early colonoscopy are useful in determining the site of bleeding and allowing haemostasis. If unsuccessful, angiographic intervention and surgery need to be considered. Videocapsule endoscopy is useful in cases where the small bowel is suspected as the source, and its results guide the performance of double- or single-balloon enteroscopy. Optimal care should involve a coordinated effort among the primary physician, endoscopist, interventional radiologist and surgeon in order to improve prognosis and subsequent management and reduce morbidity, mortality, length of stay and overall healthcare costs.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Longstreth GF. Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol. 1997;92:419–24.

    PubMed  CAS  Google Scholar 

  2. Lanas A, Garcia-Rodriguez LA, Polo-Tomas M, et al. Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice. Am J Gastroenterol. 2009;104:1633–41.

    Article  PubMed  Google Scholar 

  3. Farrell JJ, Friedman LS. Gastrointestinal bleeding in older people. Gastroenterol Clin North Am. 2000;29:1–36.

    Article  PubMed  CAS  Google Scholar 

  4. Comay D, Marshall JK. Resource utilization for acute lower gastrointestinal hemorrhage: the Ontario GI bleed study. Can J Gastroenterol. 2002;16:677–82.

    PubMed  Google Scholar 

  5. Zuccaro G Jr. Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology: Practice Parameters Committee. Am J Gastroenterol. 1998;93:1202–8.

    Article  PubMed  Google Scholar 

  6. Huang ES, Karsan S, Kanwal F, et al. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc. 2011;74:971–80.

    Article  PubMed  Google Scholar 

  7. Mujica VR, Barkin JS. Occult gastrointestinal bleeding. General overview and approach. Gastrointest Endosc Clin N Am. 1996;6:833–45.

    PubMed  CAS  Google Scholar 

  8. Yamaguchi T, Yoshikawa K. Enhanced CT for initial localization of active lower gastrointestinal bleeding. Abdom Imaging. 2003;28:634–6.

    Article  PubMed  CAS  Google Scholar 

  9. Copland A, Munroe CA, Friedland S, et al. Integrating urgent multidetector CT scanning in the diagnostic algorithm of active lower GI bleeding. Gastrointest Endoscopy. 2010;72:402–5.

    Article  Google Scholar 

  10. Day LW, Kwon A, Inadomi JM, et al. Adverse events in older patients undergoing colonoscopy: a systematic review and meta-analysis. Gastrointest Endosc. 2011;74:885–96.

    Article  PubMed  Google Scholar 

  11. Arora G, Mannalithara A, Singh G, et al. Risk of perforation from a colonoscopy in adults: a large population-based study. Gastrointest Endoscopy. 2009;69:654–64.

    Article  Google Scholar 

  12. Burtin P, Bour B, Charlois T, et al. Colonic investigations in the elderly: colonoscopy or barium enema? Aging. 1995;7:190–4.

    PubMed  CAS  Google Scholar 

  13. Sardinha TC, Nogueras JJ, Ehrenpreis ED, et al. Colonoscopy in octogenarians: a review of 428 cases. Int J Colorectal Dis. 1999;14:172–6.

    Article  PubMed  CAS  Google Scholar 

  14. Lukens FJ, Loeb DS, Machicao VI, et al. Colonoscopy in octogenarians: a prospective outpatient study. Am J Gastroenterol. 2002;97:1722–5.

    Article  PubMed  Google Scholar 

  15. Chatrenet P, Friocourt P, Ramain JP, et al. Colonoscopy in the elderly: a study of 200 cases. Eur J Med. 1993;2:411–413.

    PubMed  CAS  Google Scholar 

  16. Heuss LT, Schnieper P, Drewe J, et al. Conscious sedation with propofol in elderly patients: a prospective evaluation. Aliment Pharmacol Ther. 2003;17:1493–501.

    Article  PubMed  CAS  Google Scholar 

  17. Chua AE, Ridley LJ. Diagnostic accuracy of CT angiography in acute gastrointestinal bleeding. J Med Imaging Radiat Oncol. 2008;52:333–8.

    Article  PubMed  CAS  Google Scholar 

  18. Bandi R, Shetty PC, Sharma RP, et al. Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol. 2001;12:1399–405.

    Article  PubMed  CAS  Google Scholar 

  19. Lipof T, Sardella WV, Bartus CM, et al. The efficacy and durability of super-selective embolization in the treatment of lower gastrointestinal bleeding. Dis Colon Rectum. 2008;51:301–5.

    Article  PubMed  CAS  Google Scholar 

  20. Gillespie CJ, Sutherland AD, Mossop PJ, et al. Mesenteric embolization for lower gastrointestinal bleeding. Dis Colon Rectum. 2010;53:1258–64.

    Article  PubMed  Google Scholar 

  21. Strate LL, Syngal S. Predictors of utilization of early colonoscopy versus radiography for severe lower intestinal bleeding. Gastrointest Endosc. 2005;61:46–52.

    Article  PubMed  Google Scholar 

  22. Strate LL, Saltzman JR, Ookubo R, et al. Validation of a clinical prediction rule for severe acute lower intestinal bleeding. Am J Gastroenterol. 2005;100:1821–7.

    Article  PubMed  Google Scholar 

  23. Zuckerman GR, Prakash C. Acute lower intestinal bleeding. Part II: etiology, therapy and outcomes. Gastrointest Endosc. 1999;49:228–38.

    Article  PubMed  CAS  Google Scholar 

  24. Eliakim R. Video capsule endoscopy of the small bowel. Curr Opin Gastroenterol. 2010;26:129–33.

    Article  PubMed  Google Scholar 

  25. Strate LL, Lower GI. Bleeding: epidemiology and diagnosis. Gastroenterol Clin North Am. 2005;34:643–64.

    Article  PubMed  Google Scholar 

  26. Rhee JC, Lee KT. The causes and management of lower GI bleeding: a study based on clinical observations at Hanyang University Hospital. Gastroenterol Jpn. 1991;26(Suppl. 3):101–6.

    PubMed  Google Scholar 

  27. Meyers MA, Alonso DR, Gray GF, et al. Pathogenesis of bleeding colonic diverticulosis. Gastroenterology. 1976;71:577–83.

    PubMed  CAS  Google Scholar 

  28. Strate LL, Liu YL, Huang ES, et al. Use of aspirin or non-steroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding. Gastroenterology. 2011;140:1427–33.

    Article  PubMed  CAS  Google Scholar 

  29. Boley SJ, Sammartano R, Adams A, et al. On the nature and etiology of vascular ectasias of the colon: degenerative lesions of aging. Gastroenterology. 1977;72:650–60.

    PubMed  CAS  Google Scholar 

  30. Cubiella-Fernández J, Núñez-Calvo L, González-Vázquez E, et al. Risk factors associated with the development of ischemic colitis. World J Gastroenterol. 2010;16:4564–9.

    Article  PubMed  Google Scholar 

  31. Slotwiner-Nie PK, Brandt LJ. Infectious diarrhea in the elderly. Gastroenterol Clin North Am. 2001;30:625–35.

    Article  PubMed  CAS  Google Scholar 

  32. Tseng CA, Chen LT, Tsai KB, et al. Acute hemorrhagic rectal ulcer syndrome: a new clinical entity? Report of 19 cases and review of the literature. Dis Colon Rectum. 2004;47:895–903.

    Article  PubMed  Google Scholar 

  33. Brandt LJ, Boley SJ, Mitsudo S. Clinical characteristics and natural history of colitis in the elderly. Am J Gastroenterol. 1982;77:382–6.

    PubMed  CAS  Google Scholar 

  34. Chang CH, Lin JW, Chen HC, et al. Non-steroidal anti-inflammatory drugs and risk of lower gastrointestinal adverse events: a nationwide study in Taiwan. Gut. 2011;60:1372–8.

    Google Scholar 

  35. Goldstein JL, Chan FK, Lanas A, et al. Haemoglobin decreases in NSAID users over time: an analysis of two large outcome trials. Aliment Pharmacol Ther. 2011;34:808–16.

    Article  PubMed  CAS  Google Scholar 

  36. Chan FK, Lanas A, Scheiman J, et al. Celecoxib versus omeprazole and diclofenac in patients with osteoarthritis and rheumatoid arthritis (CONDOR): a randomised trial. Lancet. 2010;376:173–9.

    Article  PubMed  CAS  Google Scholar 

  37. Huang ES, Strate LL, Ho WW, et al. A prospective study of aspirin use and the risk of gastrointestinal bleeding in men. PLoS ONE. 2010;5(12):e15721.

    Article  PubMed  CAS  Google Scholar 

  38. Schelleman H, Brensinger CM, Bilker WB, et al. Antidepressant-warfarin interaction and associated gastrointestinal bleeding risk in a case-control study. PLoS One. 2011;6(6):e21447 [Epub 2011 Jun 24].

    Google Scholar 

  39. de Abajo FJ. Effects of selective serotonin reuptake inhibitors on platelet function: mechanisms, clinical outcomes and implications for use in elderly patients. Drugs Aging. 2011;28(5):345–67.

    Article  PubMed  Google Scholar 

  40. Carvajal A, Ortega S, Del Olmo L, et al. Selective serotonin reuptake inhibitors and gastrointestinal bleeding: a case-control study. PLoS One. 2011;6(5):e19819 [Epub 2011 May 18].

    Google Scholar 

  41. John BK, Arramraju S, Shalomov A, et al. Antiplatelet agents do not impact the hospital course in patients with gastrointestinal bleeding. J Clin Gastroenterol. 2011;45:583–9.

    Article  PubMed  CAS  Google Scholar 

  42. Kwan V, Bourke MJ, Williams SJ, et al. Argon plasma coagulation in the management of symptomatic gastrointestinal vascular lesions: experience in 100 consecutive patients with long-term follow-up. Am J Gastroenterol. 2006;101:58–63.

    Article  PubMed  CAS  Google Scholar 

  43. Jensen DM, Machicado GA, Jutabha R, et al. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med. 2000;342:78–82.

    Article  PubMed  CAS  Google Scholar 

  44. Guy GE, Shetty PC, Sharma RP, et al. Acute lower gastrointestinal hemorrhage: treatment by superselective embolization with polyvinyl alcohol particles. AJR. 1992;159:521–6.

    Article  PubMed  CAS  Google Scholar 

  45. Browder W, Cerise EJ, Litwin MS. Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg. 1986;204:530–6.

    Article  PubMed  CAS  Google Scholar 

  46. Sherman LM, Shenoy SS, Cerra FB. Selective intra-arterial vasopressin: clinical efficacy and complications. Ann Surg. 1979;189:298–302.

    Article  PubMed  CAS  Google Scholar 

  47. Setya V, Singer JA, Minken SL. Subtotal colectomy as a last resort for unrelenting, unlocalized, lower gastrointestinal hemorrhage: experience with 12 cases. Am Surg. 1992;58:295–9.

    PubMed  CAS  Google Scholar 

  48. Gianfrancisco JA, Abcarian H. Pitfalls in the treatment of massive lower gastrointestinal bleeding with “blind” subtotal colectomy. Dis Colon Rectum. 1982;25:441–5.

    Article  PubMed  CAS  Google Scholar 

  49. Vyas FL, Mathai V, Selvamani B, et al. Endoluminal formalin application for haemorrhagic radiation proctitis. Colorectal Dis. 2006;8:342–6.

    Article  PubMed  CAS  Google Scholar 

  50. Nikfarjam M, Faulx A, Laughinghouse M, et al. Feasibility of radiofrequency ablation for the treatment of chronic radiation proctitis. Surg Innov. 2010;17:92–4.

    PubMed  Google Scholar 

  51. Dall’Era MA, Hampson NB, Hsi RA, et al. Hyperbaric oxygen therapy for radiation-induced proctopathy in men treated for prostate cancer. J Urol. 2006;176:87–90.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

No sources of funding were used to assist in the preparation of this article. The author has no conflicts of interest that are directly relevant to the content of this article.

Author information

Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305-5187, USA

    George Triadafilopoulos

Authors
  1. George Triadafilopoulos
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to George Triadafilopoulos.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Triadafilopoulos, G. Management of Lower Gastrointestinal Bleeding in Older Adults. Drugs Aging 29, 707–715 (2012). https://doi.org/10.1007/s40266-012-0008-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40266-012-0008-1

Keywords

Search

Navigation